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cerebral venous thrombosis; dural sinus thrombosis

Etiology: risk factors 1) hypercoagulable state 2) oral contraceptives 3) pregnancy & the post-partum period 4) malignancy 5) sepsis 6) head trauma 7) intracranial surgery 8) smoking? 9 Covid-19 vaccine [8] Pathology: 1) superior sagittal sinus is the most common location 2) increased intracranial pressure 3) hemorrhagic infarction can occur Clinical manifestations: - signs of increased intracranial pressure - headache - worse in morning - exacerbated by Valsalva maneuver - papilledema - visual defects: diplopia - focal neurologic signs - seizures - pulsatile tinnitus Laboratory: - complete blood count (CBC) [4] - chemistry panel [4] - PT (INR) & aPTT [4] - workup for hypercoagulable state Special laboratory: - lumbar puncture with CSF analysis if diagnosis in question Radiology: - magnetic resonance venography (test of choice) - CT venography - CT or MRI of the brain without contrast is generally normal - cerebral angiography (expensive, invasive) Differential diagnosis: - meningitis - pseudotumor cerebri Complications: - in patients with cerebral venous sinus thrombosis after SARS-CoV2 vaccination 67% had thrombosis with thrombocytopenia - 24% of these comatose at presentation - 68% with intracerebral hemorrhage - 36% with concomitant thromboembolism - 47% mortality during hospitalization [9] - epilespy [10,11] - supratentorial lesions increased risk for both presenting & early seizures - presenting seizures increased risk of recurrent seizures within 2 weeks [10] - DIAS3 score (freely available online) is a simple tool that can help predict the risk of post-cerebral vein thrombosis epilepsy [11] Management: - smoking cessation [1] - discontinuation of oral contraceptives - anticoagulation - duration 3-6 months if transient risk factor, 6-12 months if unexplained but without risk for thrombophilia, lifelong if recurrent or risk of thrombophilia [2] - bleeding, progressive cerebral venous thrombosis, & recurrent venous thromboembolism similar with dabigatran or warfarin [7] - for Covid-19 associated cerebral sinus venous thrombosis suggested treatment with argatroban, danaparoid, fondaparinux, or direct oral anticoagulants +/- intravenous immune globulin +/- high-dose glucocorticoids [8]

Related

superior sagital sinus (superior longitudinal sinus)

Specific

cavernous sinus thrombosis

General

deep vein thrombosis (DVT)

References

  1. UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Medical Knowledge Self Assessment Program (MKSAP) 16, 17. 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2021.
  3. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med. 2005 Apr 28;352(17):1791-8. PMID: 15858188
  4. Bushnell C et al Guidelines for the Pevention of Stroke in Women: A Statement for Healthcare Professionals From the American Heart Association/ American Stroke Association. Stroke. Feb 6, 2015 PMID: 24503673 http://stroke.ahajournals.org/content/early/2014/02/06/01.str.0000442009.06663.48.full.pdf+html
  5. Pikija S, Mutzenbach JS Septic Cerebral Venous Thrombosis. N Engl J Med 2015; 373:1553. October 15, 2015 PMID: 26465988 http://www.nejm.org/doi/full/10.1056/NEJMicm1415937
  6. Sparaco M, Feleppa M, Bigal ME. Cerebral Venous Thrombosis and Headache--A Case-Series. Headache. 2015 Jun;55(6):806-14. PMID: 26084237
  7. Ferro JM, Coutinho JM, Dentali F et al. Safety and efficacy of dabigatran etexilate vs dose-adjusted warfarin in patients with cerebral venous thrombosis: A randomized clinical trial. JAMA Neurol 2019 Sep 3 PMID: 31479105 Free PMC Article https://jamanetwork.com/journals/jamaneurology/fullarticle/2749167
  8. Cines DB, Bussel JB SARS-CoV-2 Vaccine-Induced Immune Thrombotic Thrombocytopenia. N Engl J Med. 2021. April 16. PMID: 33861524 https://www.nejm.org/doi/full/10.1056/NEJMe2106315 - Rizk JG, Gupta A, Sardar P et al Clinical Characteristics and Pharmacological Management of COVID-19 Vaccine- Induced Immune Thrombotic Thrombocytopenia With Cerebral Venous Sinus Thrombosis. A Review. JAMA Cardiol. Published online August 10, 2021 PMID: 34374713 https://jamanetwork.com/journals/jamacardiology/fullarticle/2783051
  9. Sanchez van Kammen M, Aguiar de Sousa D, Poli S et al Characteristics and Outcomes of Patients With Cerebral Venous Sinus Thrombosis in SARS-CoV-2 Vaccine-Induced Immune Thrombotic Thrombocytopenia. JAMA Neurol. 2021;78(11):1314-1323 PMID: 34581763 PMCID: PMC8479648 (available on 2022-09-28) https://jamanetwork.com/journals/jamaneurology/fullarticle/2784622
  10. Ferro JM, Canhao P, Bousser MG et al Early seizures in cerebral vein and dural sinus thrombosis: risk factors and role of antiepileptics. Stroke. 2008 Apr;39(4):1152-8. PMID: 18309177
  11. Lindgren E, Shu L, Simaan N et al Development and Validation of a Clinical Score to Predict Epilepsy After Cerebral Venous Thrombosis. JAMA Neurol. 2024 Oct 21. PMID: 39432281 - DIAS3 calculator to predict epilepsy after CVT https://cerebralvenousthrombosis.com/professionals/dias-3/